title: Risks and benefits of estrogen therapy for a male-to-female transsexual with a prothrombin gene mutation.
abstract: OBJECTIVE
  We present the case of a male-to-female transsexual person in her 20s requesting hormone therapy in the setting of a history of a deep venous thrombosis and pulmonary embolus and carrying the prothrombin G20210A gene mutation.
  
  
  METHODS
  We interviewed the patient and reviewed her medical records. We carefully weighed the risks and benefits of hormone therapy and took into account two important ethical principles: beneficence (to act in the patient's best interest) and nonmaleficence (to avoid harm).
  
  
  RESULTS
  Our patient presented to an outside facility with weight loss, generalized weakness, right lower extremity swelling, and chest pain. She was diagnosed with a pulmonary embolus and extensive deep venous thrombus by computed tomography (CT) scan and Doppler ultrasound, respectively. She was found to carry the prothrombin G20210A gene mutation. She was treated with anticoagulation therapy for 12 months, which was restarted prior to beginning therapy with transdermal estrogen.
  
  
  CONCLUSIONS
  While the exact risk of recurrent deep venous thrombosis and pulmonary embolus in our patient is unknown, we recommended that hormone therapy should only be given in conjunction with anticoagulation. We speculate that this strategy would allow the patient to experience the benefits to her overall well-being with hormone therapy while reducing the risks of venous thrombosis to acceptable levels. Prospective long-term follow-up of this patient is needed to verify the benefits and risk of the intervention chosen.
authors.affiliation: School of Medicine and Health Sciences, George Washington University, Washington DC.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Laidlaw
authors.forename: Michael S
authors.initials: MS
authors.lastname: Irwig
mesh_terms: D000279:Administration, Cutaneous; D000925:Anticoagulants / Q000627:therapeutic use; D004967:Estrogens / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D005260:Female; D006801:Humans; D009154:Mutation / Q000235:genetics* / Q000502:physiology*; D011516:Prothrombin / Q000235:genetics*; D018570:Risk Assessment; D013927:Thrombosis / Q000209:etiology; D014057:Tomography, X-Ray Computed; D063106:Transgender Persons; D055815:Young Adult; D008297:Male
chemical_list: D000925:Anticoagulants; D004967:Estrogens; D011516:Prothrombin